The nurse is providing care for a patient diagnosed with an ischemic stroke on the left side of the brain with opposite side affected extremities. The nurse notices that the patient does not easily reach items placed at the bedside. In which area does the nurse place items for easy access?

Left Side

Right Side

Directly in front

Where the patient wants

Answer and Explanation

The Correct Answer is B

A. Placing items on the left side would not be appropriate for a patient with a right-sided weakness (hemiparesis) due to a left-sided ischemic stroke. This would make it harder for the patient to reach the items.

B. Placing items on the right side of the patient is the best option. Since the patient has weakness on the right side, they would have better access to items placed on the unaffected side (left side of the body).

C. Placing items directly in front of the patient could be helpful, but it depends on the severity of the stroke and the patient's ability to move and reach forward. It may not be as effective if the patient has limited mobility.

D. Placing items where the patient wants is a good practice, but the nurse should ensure the placement is practical for the patient's abilities. It is more important to place items on the right side to optimize access.

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Correct Answer is C

Explanation

A. Palpebral angle rigid, right and left angles is not a part of the PERRLA assessment. The term refers to the space between the eyelids, which is not assessed with the PERRLA acronym.

B. Patient's eyes round, regular, lively, active is a description of the general appearance of the eyes but does not correspond to the PERRLA acronym, which specifically addresses the pupils' response to light and accommodation.

C. PERRLA stands for Pupils Equal, Round, and Reactive to Light and Accommodation. This means the pupils should be equal in size, round in shape, react to light (constricting when exposed to light), and accommodate (adjust) when focusing on near or far objects. This is a standard neurological assessment used to evaluate the functioning of the eyes and the nervous system.

D. Pupils equilateral, regular, round, little accommodation does not accurately describe PERRLA. The correct term is "accommodation," which refers to the pupils' ability to adjust when focusing on near or far objects, not "little accommodation."

A. Increased LOC and increased range of motion B. Restlessness, irritability, and decreased LOC C. Pain in the calf and neck D. Fever and chills

Correct Answer is B

Explanation

A. Increased LOC (level of consciousness) and increased range of motion are not typical symptoms of increased intracranial pressure (ICP). In fact, ICP usually leads to a decreased level of consciousness, not an increase.

B. Restlessness, irritability, and decreased LOC are early signs of increased intracranial pressure. As pressure inside the skull rises, the brain becomes less able to function normally, leading to changes in behavior and cognition, such as restlessness and irritability, followed by a decrease in consciousness.

C. Pain in the calf and neck is not a typical symptom of ICP. While neck pain may occur with certain neurological conditions, it is not a hallmark of increased intracranial pressure.

D. Fever and chills are not initial symptoms of ICP. These symptoms are more indicative of infection, such as meningitis, rather than increased intracranial pressure.

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The nurse is providing care for a patient diagnosed with an ischemic stroke on the left side of the brain with opposite side affected extremities. The nurse notices that the patient does not easily reach items placed at the bedside. In which area does the nurse place items for easy access?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse performs a visual assessment on a patient and documents the findings using the acronym PERRLA. Which assessment finding does PERRLA indicate?

Correct Answer is C

Explanation

What are the initial symptoms of ICP (increased intracranial pressure)?

Correct Answer is B

Explanation

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